The role of chemotherapy in locally advanced, metastatic and recurrent cervical cancer

Therapeutic Effects of Natural Products on Cervical Cancer: Based on Inflammatory Pathways

Inflammation is a protective response of the body to an irritant. When an inflammatory response occurs, immune cells are recruited to the injury, eliminating the irritation. The excessive inflammatory response can cause harm to the organism. Inflammation has been found to contribute to cervical cancer if there is a problem with the regulation of inflammatory response. Cervical cancer is one of the most common malignant tumors globally, and the incidence tends to be younger. The harm of cervical cancer cannot be ignored. The standard treatments for cervical cancer include surgery, radiotherapy and chemotherapy. However, the prognosis for this treatment is poor, so it is urgent to find a safer and more effective treatment. Natural products are considered excellent candidates for the treatment of cervical cancer. In this review, we first describe the mechanisms by which inflammation induces cervical cancer. Subsequently, we highlight natural products that can treat cervical cancer through inflammatory pathways. We also introduce natural products for the treatment of cervical cancer in clinical trials. Finally, methods to improve the anticancer properties of natural products were added, and the development status of natural products was discussed.

Potential Mechanisms of Plant-Derived Natural Products in the Treatment of Cervical Cancer

Cervical cancer is the second most common gynecological malignancy globally; it seriously endangers women’s health because of its high morbidity and mortality. Conventional treatments are prone to drug resistance, recurrence and metastasis. Therefore, there is an urgent need to develop new drugs with high efficacy and low side effects to prevent and treat cervical cancer. In recent years, plant-derived natural products have been evaluated as potential anticancer drugs that preferentially kill tumor cells without severe adverse effects. A growing number of studies have shown that natural products can achieve practical anti-cervical-cancer effects through multiple mechanisms, including inhibition of tumor-cell proliferation, induction of apoptosis, suppression of angiogenesis and telomerase activity, enhancement of immunity and reversal of multidrug resistance. This paper reviews the therapeutic effects and mechanisms of plant-derived natural products on cervical cancer and provides references for developing anti-cervical-cancer drugs with high efficacy and low side effects.

Changes of proportions of circulating lymphocyte subsets in cancer patients after chemotherapy

BACKGROUND

It remains unknown how chemotherapy affects circulating lymphocyte subsets and whether the pattern of change is related to prognosis in cancer patients.

METHODS

Cancer patients who received chemotherapy between 2018/03/01 and 2019/12/31 were enrolled from the Hefei Cancer Hospital, Chinese Academy of Sciences. Peripheral blood samples were collected before and 3 weeks after the start of chemotherapy, and the proportions of T cells (CD3+), helper T cells (CD3+CD4+), cytotoxic T cells (CD3+CD8+), B cells (CD19+), and Natural killer (NK) cells (CD3-CD56+) were examined by flow cytometry. Multivariable logistic regression analysis was employed to explore risk factors associated with overall survival within 12 months after the start of chemotherapy.

RESULTS

A total of 167 patients with cancer were included in the analysis, including 14 cases of cervical cancer, 18 cases of breast cancer, 33 cases of gastric cancer, 48 cases of lung cancer, 21 cases of colorectal cancer, and 33 cases of esophageal cancer. The proportion of T cells (72.58%±10.44% vs. 80.67%±11.63%, P<0.001) and cytotoxic T cells (25.38%±8.87% vs. 39.20%±12.26%, P<0.001) significantly increased, while the proportion of helper T cells (45.58%±10.19% vs. 41.98%±10.47%, P<0.001), B cells (15.10%±5.23% vs. 11.29%±5.60%, P<0.001), and NK cells (19.33%±7.54% vs. 18.28%±7.62%, P<0.001) significantly decreased at 3 weeks after chemotherapy when compared to baseline levels. The overall mortality rate was 14.97% (25/167) within 1 year after the start of chemotherapy. Patients who survived showed a significantly less increase in cytotoxic T cells (13.38%±8.28% vs. 17.28%±7.97%, P=0.030) and less decrease in B cells (-3.58%±2.81% vs. -5.29%±3.03%, P=0.006) when compared to non-survivors. Greater decreases in helper T cells (OR 0.81, 95% CI, 0.68-0.96) and B cells (OR 0.72, 95% CI, 0.59-0.87), and a greater increase in cytotoxic T cells (OR 1.09, 95% CI, 1.03-1.16) were risk factors for poor overall survival.

CONCLUSIONS

Circulating lymphocyte subsets of cancer patients presented characteristic changes after chemotherapy. Patients with a greater decrease in helper T cells and B cells, or greater increase in cytotoxic T cells, may have worse survival.

Bone recurrence after radical hysterectomy and lymphadenectomy in early-stage cervical cancer

Objective:

To present the clinical, surgical, and pathologic features of bone recurrence in patients who underwent radical hysterectomy for early-stage uterine cervical cancer.

Materials and Methods:

Data of 412 patients who underwent type III radical hysterectomy and pelvic ± paraaortic lymphadenectomy for stage 1B-2A epithelial cervical cancer were reviewed. Seven (1.7%) patients with bone recurrence in the first recurrence were included in the study.

Results:

The median follow-up of the main cohort (n=412) was 46 (range=1-300) months. In this period, recurrence developed in 53 (12.9%) patients and recurrence was observed in bone in 13.2% (7 of 53) of these recurrences. Time to recurrence ranged from 9 to 45 months. Of the recurrences, five were in the axial skeleton and two were in the appendicular skeleton. Recurrence was observed in lumbar vertebrae in three patients, thoracic vertebrae in one patient, sacral vertebrae in one patient, lumbosacral vertebrae in one patient, and the left femur in two patients. Four patients had multiple recurrence in 3 patients despite isolated bone recurrence. Patients with multiple recurrences died within 6-25 months. All isolated bone recurrences were in the axial skeleton. Complete clinical response with salvage therapy was achieved in two patients with isolated bone recurrence.

Conclusion:

Complete clinical response and long postoperative survival can be achieved with salvage treatment when bone recurrence is solitary in cervical cancers.

The enhanced inhibitory effect of different antitumor agents in self-microemulsifying drug delivery systems on human cervical cancer HeLa cells

The aim of this study was to develop topical self-microemulsifying drug delivery systems (SMEDDS) containing antitumor agents (bleomycin, cisplatin and ifosfamide) and to investigate their inhibitory potential in SMEDDS on human cervical cancer HeLa cells. The physicochemical properties of cytostatic drug loaded SMEDDS were characterized. The cytotoxicity of main components of SMEDDS was also investigated. Their IC₅₀ values were determined. HeLa cells were treated by different concentrations of cisplatin, bleomycin and ifosfamide alone and in various SMEDDS. The inhibitory effect on cell growth was analyzed by MTT cell viability assay. Inflammation is a driving force that accelerates cancer development. The inhibitory effect of these antitumor agents has also been tested on HeLa cells in the presence of inflammatory mediators (IL-1-β, TNF-α) as an in vitro model of inflamed human cervix. Significant differences in the cytotoxicity of cytostatic drugs alone and in SMEDDS have been found in a concentration-dependent manner. The self-micro emulsifying system may potentiate the effectiveness of bleomycin, cisplatin and ifosfamide topically. The effect of SMEDDS containing antitumor agents was decreased significantly in the presence of inflammatory mediators. According to our experiments, the optimal SMEDDS formulation is 1:1:2:6:2 ratios of Isopropyl myristate, Capryol 90, Kolliphor RH 40, Cremophor RH40, Transcutol HP and Labrasol. It can be concluded that SMEDDS may increase the inhibitory effect of bleomycin, ifosfamide and cisplatin on human cervical cancer HeLa cells. Inflammation on HeLa cells hinders the effectiveness of SMEDDS containing antitumor agents. Our results might ensure useful data for development of optimal antitumor formulations.

MicroRNA-181a enhances the chemoresistance of human cervical squamous cell carcinoma to cisplatin by targeting PRKCD

MicroRNAs(miRNAs) are involved in regulating the response of cancer cells to various therapeutic interventions, but their involvement in the chemoresistance of human cervical squamous cell carcinoma is not fully understood. We found miR-181a was significantly up-regulated in specimens from patients with chemoresistant cervical squamous cell carcinoma. In this study, we aimed to clarify the role of miR-181a in regulating the chemoresistance of cervical cancer. Two human cervical squamous cancer cell lines, SiHa and Me180, were used. Enforced expression of miR-181a enhanced chemoresistance to cisplatin in cervical cancer cells through apoptosis reversion. In a nude mouse xenograft model, the overexpression of miR-181a markedly inhibited the therapeutic response to cisplatin. PRKCD, a target gene of miR-181a and a promoter of apoptosis, was negatively regulated by miR-181a. We found that the effect of miR-181a on chemoresistance was mediated by PRKCD. Additionally, silencing of PRKCD yielded an effect similar to that of miR-181a up-regulation and inhibited apoptosis in cervical cancer cells. Our findings suggest that miR-181a may function as an oncogene and induce chemoresistance in cervical squamous cell carcinoma cells at least in part by down-regulating PRKCD, thus may provide a biomarker for predicting chemosensitivity to cisplatin in patients with cervical squamous cancer.

Treatment options in recurrent cervical cancer (Review)

The management of recurrent cervical cancer depends mainly on previous treatment and on the site and extent of recurrence. Concurrent cisplatin-based chemo-radiation is the treatment of choice for patients with pelvic failure after radical hysterectomy alone. However, the safe delivery of high doses of radiotherapy is much more difficult in this clinical setting compared with primary radiotherapy. Pelvic exenteration usually represents the only therapeutic approach with curative intent for women with central pelvic relapse who have previously received irradiation. In a recent series, the 5-year overall survival and operative mortality after pelvic exenteration ranged from 21 to 61% and from 1 to 10%, respectively. Free surgical margins, negative lymph nodes, small tumour size and long disease-free interval were associated with a more favourable prognosis. Currently, pelvic reconstructive procedures (continent urinary conduit, low colorectal anastomosis, vaginal reconstruction with myocutaneous flaps) are strongly recommended after exenteration. Concurrent cisplatin-based chemo-radiation is the treatment of choice for isolated para-aortic lymph node failure, with satisfactory chances of a cure in asymptomatic patients. Chemotherapy is administered with palliative intent to women with distant or loco-regional recurrences not amenable by surgery or radiotherapy. Cisplatin is the most widely used drug, with a response rate of 17-38% and a median overall survival of 6.1-7.1 months. Cisplatin-based combination chemotherapy achieves higher response rates (22-68%) when compared with single-agent cisplatin, but median overall survival is usually less than one year. In a recent Gynecologic Oncology Group (GOG) trial the combination topotecan + cisplatin obtained a significantly longer overall survival than single-agent cisplatin in patients with metastatic or recurrent or persistent cervical cancer. A subsequent GOG study showed a trend in terms of longer overall survival and better quality of life for the doublet cisplatin + paclitaxel vs. the doublets cisplatin + topotecan, cisplatin + vinorelbine, and cisplatin + gemcitabine. Molecularly targeted therapy may represent a novel therapeutic tool, but its use alone or in combination with chemotherapy is still investigational.

Phase II study of tirapazamine plus cisplatin in patients with advanced or recurrent cervical cancer

The aim of this study was to evaluate the activity and toxicity of a tirapazamine (TPZ)/cisplatin drug combination in patients with stage IV or recurrent cervical cancer. The chemotherapy was administered for a maximum of eight cycles every 21 days. TPZ was administered intravenously at 330 mg/m(2) over a 2-h infusion, followed 1 h later by cisplatin intravenously at 75 mg/m(2) over 1 h on day 1. All patients received antiemetics including dexamethasone, ondansetron, and lorazepam. Subsequent doses were unchanged, reduced, or omitted according to observed toxicity and protocol guidelines. Response evaluation was performed every two cycles. Thirty-six patients with stage IV or recurrent cervical cancer were treated. Ninety-four percent of patients had prior radiotherapy. Two patients had prior chemotherapy. There were two complete responses and eight partial responses (27.8%). An additional 11 patients (30.6%) had stable disease as their best response. Response rate was greater in tumors outside of the previously radiated field (44.4% vs 11.1%). The median time to progression was 32.7 weeks. The most frequent grade 3 or 4 adverse events were nausea, vomiting, and fatigue, which occurred in 30.6%, 25%, and 22% of subjects, respectively. Anemia was the most frequent grade 3 or 4 hematologic toxicity at 8.3%. We conclude that the combination of cisplatin and TPZ was reasonably well tolerated in patients with recurrent or advanced cervical cancer. Further evaluation of this drug combination may be warranted.

Indications for primary and secondary exenterations in patients with cervical cancer

OBJECTIVE

Fifty years after the introduction of exenterative surgery in gynecologic oncology, the indication for primary and secondary exenteration is controversially discussed in cervical cancer patients. In addition, the term "palliative exenteration" is not precisely defined. We evaluate the role of primary exenteration in patients with stage IVA cervical cancer and the role of secondary palliative exenteration.

METHODS

The study retrospectively analyzed surgical and oncologic data of 55 patients who underwent exenterative surgery in the Department of Gynecology at the University of Jena between February 1998 and January 2004. Primary surgery was performed in 20 patients with laparoscopically confirmed stage IVA cervical cancer, while 35 patients with recurrent cervical cancer underwent secondary exenteration. Fifty-one had total, 3 posterior and 1 anterior exenteration. Survival was analyzed in relation to the patient's age, indication (primary versus secondary, curative versus palliative), previous therapy (operation, radiation, chemotherapy, radiochemotherapy), histology, resection margins, pelvic nodal involvement, time interval from primary therapy to recurrence, type of exenteration and adjuvant therapy. Early and late postoperative complications as well as perioperative mortality were reviewed.

RESULTS

The overall cumulative survival of all patients after exenteration was 36.8% at 5 years with 52.5% in the primary group and 26.7% in the recurrent one (p=0.0472). Complications were noted in 56.9% of patients, most commonly fistulas or gastrointestinal complications. Operative mortality was 5.5%. Survival correlated significantly with the time interval between primary treatment and recurrence (within 1-2 years 16.8% five-year survival, 2-5 years 28%, >5 years 83.2%, p=0.0105) as well as with curative or palliative intention (2-year survival rate of 60% in patients with curative intent, 10.5% in those with palliative intent, p=0.0001) and with tumor-free resection margins (2-year survival of 10.2% for positive margins, 5-year survival of 55.2% for negatives ones, p=0.0057). The age, the type of exenteration, the histologic type and the metastatic spread to pelvic lymph nodes had no significant influence on long-term survival.

CONCLUSION

In patients with histopathologically confirmed stage IVA cervical cancer primary, exenteration is a valid alternative to primary chemoradiation. In patients with persistent or recurrent tumor limited to the pelvis, secondary exenteration should be offered in the absence of other therapeutic options. Palliative and curative attempts can best be differentiated by the resection margin status.

Management of cervical cancer

AIMS

The aim of the article was to review the current approach to management of cervical cancer.

METHODS

The relevant literature has served as a source for review of different options applied in the management of cervical cancer.

RESULTS

Treatment of invasive cervical cancer is affected by the stage of the disease, which is based on clinical evaluation. Microinvasive carcinoma of the cervix has limited metastatic potential and therefore is most likely curable by non-radical treatment. There is no standard management of stage Ib-IIa cervical carcinoma. Both radical surgery and radical radiotherapy have proven to be equally effective, but differ in associated morbidity and complications. Most often, stage Ib1 cervical cancer is treated by radical hysterectomy with pelvic lymphadenectomy. Laparoscopically assisted radical vaginal hysterectomy has shown similar efficacy and recurrence rates. Radical vaginal trachelectomy with laparoscopic pelvic lymphadenectomy may be an option in small cervical cancer where preservation of fertility is desired. There is lot of conflicting published work regarding the treatment of bulky stage Ib-IIa cervical cancer. While some centers are performing primary surgery as for Ib1 disease followed by tailored postoperative radiation with or without chemotherapy, the others are in favor of primary chemo-radiation therapy. Neoadjuvant chemotherapy followed by radical surgery has emerged as a possible alternative, which may improve a survival in patients with stage Ib2 disease. Concomitant chemoradiation is becoming a new standard in treatment of advanced disease, because it has been clearly shown to improve disease-free, progression-free and overall survival. Management of recurrent disease depends on previous treatment, site and extent of recurrence, disease-free interval and patient's performance status.

CONCLUSIONS

Treatment decisions should be individualized and based on multiple factors including the stage of the disease, age, medical condition of the patient, tumor-related factors and treatment preferences, to yield the best cure with minimum complications.

Magnetic resonance imaging in the characterization of pelvic masses

Female pelvic masses most commonly arise from the reproductive tract, although masses may arise from other structures in the pelvis, such as the gastrointestinal or urinary tracts. The evaluation of a pelvic mass often begins with the physical exam and proceeds to ultrasound, computed tomography, or magnetic resonance imaging. Each of these modalities has a role in the work-up of pelvic masses and each modality has inherent advantages and disadvantages. The focus of this article is to demonstrate the imaging features and role of MRI, in contrast to CT, for detecting, characterizing, and staging pelvic masses. The differential diagnosis for pelvic masses is extremely broad. Clinical history, precise anatomical localization, and MR imaging characterization can significantly narrow the differential diagnosis. With recent advances in therapeutic strategies, a non-invasive, preoperative diagnosis is highly desirable to suggest prognosis and to tailor the treatment approach.

Pre-exenterative chemotherapy, a novel therapeutic approach for patients with persistent or recurrent cervical cancer

Background

Most cervical cancer patients with pelvic recurrent or persistent disease are not candidates for exenteration, therefore, they only receive palliative chemotherapy. Here we report the results of a novel treatment modality for these patients pre-exenterative chemotherapy- under the rational that the shrinking of the pelvic tumor would allow its resection.

Methods

Patients with recurrent or persistent disease and no evidence of systemic disease, considered not be candidates for pelvic exenteration because of the extent of pelvic tumor, received 3-courses of platinum-based chemotherapy. Response was evaluated by CT scan and bimanual pelvic examination; however the decision to perform exenteration relied on the physical findings. Toxicity to chemotherapy was evaluated with standard criteria. Survival was analyzed with the Kaplan-Meier method.

Results

Seventeen patients were studied. The median number of chemotherapy courses was 4. There were 9 patients who responded to chemotherapy, evaluated by bimanual examination and underwent pelvic exenteration. Four of them had pathological complete response. Eight patients did not respond and were not subjected to surgery. One patient died due to exenteration complications. At a median follow-up of 11 months, the median survival for the whole group was 11 months, 3 months in the non-operated and 32 months in those subjected to exenteration.

Conclusion

Pre-exenterative chemotherapy is an alternative for cervical cancer patients that are no candidates for exenteration because of the extent of the pelvic disease. Its place in the management of recurrent disease needs to be investigated in randomized studies, however, its value for offering long-term survival in some of these patients with no other option than palliative care must be stressed.